Prospective Trial of Real-Time Electronic Surveillance to Expedite Early Care of Severe Sepsis

Nelson, Jessica; Smith, Barbara; Jared, Jeremy D.; Younger, John G.

doi:10.1016/j.annemergmed.2010.12.008

Cited by 103 publications

(96 citation statements)

References 6 publications

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“…In pediatric patients, single samples were collected from 1,354 of 1,490 patients (90.0%), whereas in adult patients, single samples were collected from 1,386 of 6,078 patients (22.8%). The median time between ED arrival and blood sample acquisition was 97 min (interquartile range [IQR], 51 to 167 min), a delay similar to what we reported previously in the care of patients with sepsis in this ED (12). The mean duration between the documented time of specimen collection and delivery to the laboratory was 38 min (IQR, 16 to 40 min).…”

Section: Resultsmentioning

confidence: 51%

“…The number of new patient arrivals, patient length of stay (LOS) in the ED, and the patient triage acuity score for each hour between 31 October 2010 and 30 October 2011 were gathered from the ED clinical information system at UMHS (Centricity 7.5.x; General Electric Healthcare, Piscataway, NJ) as we described previously (11,12). Hourly occupancy was chosen over more complex crowding metrics and was reconstructed from arrival and LOS data (13).…”

Section: Emergency Department Characteristics and Determination Of Acmentioning

confidence: 99%

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Impact of Hourly Emergency Department Patient Volume on Blood Culture Contamination and Diagnostic Yield

et al. 2013

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Emergency departments (EDs) are an important diagnostic site for outpatients with potentially serious infections. EDs frequently experience high patient volumes, and crowding has been shown to negatively impact the delivery of early care for serious infections, such as pneumonia. Here, we hypothesized that other important factors in the early care of infectious diseases, the rate of blood culture contamination and the accurate detection of pathogens, would be sensitive to ED operational stress, as proper collection requires fastidious attention to technique and timing. We related all blood samples collected over 1 year and their rates of recovery of likely contaminants and pathogens to the number of patients being cared for in the ED at the time of sample collection. Likely pathogens and contaminants were classified through combined microbiological and manual chart review criteria. Zero-inflated Poisson regression was used to relate crowding to culture results. Blood samples were obtained from 7,586 patients over 82,521 adult and pediatric patient visits. The unadjusted rates of recovering a likely pathogen or a likely contaminant were 8.0% and 3.7%, respectively. Periods of increased crowding (3rd and 4th quartiles of hourly occupancy) were significantly associated (P < 0.01) with increased rates of contamination (relative risk, 1.23 compared to the least busy quartile). Collecting samples for culture during busy times was also associated with a reduced likelihood of recovering a likely pathogen (relative risk, 0.93 compared to the least busy quartile). ED crowding was associated with degraded performance of blood cultures, both increasing the rate of contamination and decreasing the diagnostic yield. Despite considerable efforts to reduce their incidence, contaminated blood cultures continue to be a significant clinical problem. Ongoing multicenter monitoring in the United States places the median rate of contamination at just under 3% (lower national quartile, 2.15%; upper quartile, 3.67%) (1). The clinical and financial impacts of contaminated cultures have been examined by numerous groups; the most recently published results indicate that among patients undergoing blood culture during emergency department (ED) evaluation and subsequent admission to the hospital, a false-positive culture adds an estimated $8,700 (2008 U.S. dollars) and an additional day of hospitalization (2). Excess contamination rates are driven primarily by a lack of operator fastidiousness during the collection process (3). As such, interventions such as dedicated phlebotomy teams, prepackaged blood culture kits, and the use of sterile gloves have helped decrease contamination rates (4, 5).One clinical setting about which little is known regarding blood culture contamination is the emergency department (ED). EDs are an important and common site for initial diagnosis and treatment; more than 136 million visits took place in 2009, the most recent year for which Centers for Disease Control and Prevention data are available (6). Increasingly...

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Section: Resultsmentioning

confidence: 51%

Section: Emergency Department Characteristics and Determination Of Acmentioning

confidence: 99%

Impact of Hourly Emergency Department Patient Volume on Blood Culture Contamination and Diagnostic Yield

et al. 2013

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“…The two studies 14, 16 that defined sepsis as requiring evidence of shock had a substantially lower prevalence (0.8-4.7%) compared to the two studies 10, 13 that defined sepsis as having only two or more SIRS criteria with a presumed diagnosis of an infection (27.8%-32.5%).…”

Section: Resultsmentioning

confidence: 88%

“…Five articles evaluated the diagnostic accuracy of sepsis identification 10, 13-16 and five articles 10, 14, 17-19 evaluated the effectiveness of automated electronic sepsis alerts on sepsis process measures and patient outcomes. All articles were published between 2009 and 2014 and were single-site studies conducted at academic medical centers (Tables 1 and 2).…”

Section: Resultsmentioning

confidence: 99%

Diagnostic accuracy and effectiveness of automated electronic sepsis alert systems: A systematic review

Makam

Nguyen

Auerbach

2015

Journal of Hospital Medicine

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Background Although timely treatment of sepsis improves outcomes, delays in administering evidence-based therapies are common. Purpose To determine whether automated real-time electronic sepsis alerts can: 1) accurately identify sepsis, and 2) improve process measures and outcomes. Data Sources We systematically searched MEDLINE, Embase, The Cochrane Library, and CINAHL from database inception through June 27, 2014. Study Selection Included studies that empirically evaluated one or both of the prespecified objectives. Data Extraction Two independent reviewers extracted data and assessed the risk of bias. Diagnostic accuracy of sepsis identification was measured by sensitivity, specificity, positive (PPV) and negative predictive values (NPV) and likelihood ratios (LR). Effectiveness was assessed by changes in sepsis care process measures and outcomes. Data Synthesis Of 1,293 citations, 8 studies met inclusion criteria, 5 for the identification of sepsis (n=35,423) and 5 for the effectiveness of sepsis alerts (n=6,894). Though definition of sepsis alert thresholds varied, most included systemic inflammatory response syndrome criteria ± evidence of shock. Diagnostic accuracy varied greatly, with PPV ranging from 20.5-53.8%, NPV 76.5-99.7%; LR+ 1.2-145.8; and LR- 0.06-0.86. There was modest evidence for improvement in process measures (i.e., antibiotic escalation), but only among patients in non-critical care settings; there were no corresponding improvements in mortality or length of stay. Minimal data were reported on potential harms due to false positive alerts. Conclusions Automated sepsis alerts derived from electronic health data may improve care processes but tend to have poor positive predictive value and do not improve mortality or length of stay.

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“…Nelson et al used a real-time electronic surveillance algorithm in the emergency room that screened for SIRS and hypotension and found a 54% positive predictive value. The authors noted that their system usually failed to identify the patient before the clinician [22]. Meurer et al reported on an electronic sepsis screen of geriatric patients in the emergency room that screened for SIRS and sent an automatic page to clinicians.…”

Section: Discussionmentioning

confidence: 99%

Can a Computerized Sepsis Screening and Alert System Accurately Diagnose Sepsis in Hospitalized Floor Patients and Potentially Provide Opportunities for Early Intervention? A Pilot Study

Zuick¹,

Asch²

2016

Intensive & Crit Care

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Prospective Trial of Real-Time Electronic Surveillance to Expedite Early Care of Severe Sepsis

Cited by 103 publications

References 6 publications

Impact of Hourly Emergency Department Patient Volume on Blood Culture Contamination and Diagnostic Yield

Impact of Hourly Emergency Department Patient Volume on Blood Culture Contamination and Diagnostic Yield

Diagnostic accuracy and effectiveness of automated electronic sepsis alert systems: A systematic review

Can a Computerized Sepsis Screening and Alert System Accurately Diagnose Sepsis in Hospitalized Floor Patients and Potentially Provide Opportunities for Early Intervention? A Pilot Study

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